R004 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21 August 2009
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Investigation Report No. 2010 – R004 August 2010 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 Document History Title Malahide Viaduct Collapse on the Dublin to Belfast Line on the 21st August 2009 Document type Investigation Report Document number R2010 – 004 Document issue date 16/08/2010 Revision Revision Summary of changes number date 1 17/08/2010 Photograph 3 caption change 2 20/10/2010 Report and footers renumbered. Typographical error correction in paragraph 5 of Section 11. Figure 19 is now Figure 22, Figures 20 – 22 renamed. Additional RAIU and RSC terms added to Section 46.1. RAIU ii Investigation Report 2010 – R004 Rev 2 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 Role of the Railway Accident Investigation Unit The Railway Accident Investigation Unit (RAIU) is an independent investigation unit within the Railway Safety Commission (RSC). The RAIU conducts investigations into accidents and incidents. The purpose of an investigation by the RAIU is to improve railway safety by establishing, in so far as possible, the cause or causes of an accident or incident with a view to making safety recommendations for the avoidance of accidents in the future, or otherwise for the improvement of railway safety. It is not the purpose of an investigation to attribute blame or liability. The RAIU‟s investigations are carried out in accordance with the Railway Safety Act 2005 and European railway safety directive 2004/49/EC. Any enquiries about this report should be sent to: RAIU Trident House Blackrock County Dublin Ireland RAIU iii Investigation Report 2010 – R004 Rev 2 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 Executive Summary On the 21st August 2009 as an Iarnród Éireann passenger service, travelling from Balbriggan to Pearse, passed over the Malahide Viaduct the driver witnessed a section of the viaduct beginning to collapse into Broadmeadow Estuary. The driver reported this to the controlling signalman who immediately set all relevant signals to danger ensuring no trains travelled over the viaduct. Within minutes of the report of the accident, by the driver, Pier 4 of the Malahide Viaduct had collapsed into the Broadmeadow Estuary. All post accident emergency procedures were properly employed by the operating staff resulting in no fatalities or injuries to any members of the public or staff. At the time of the accident, the Malahide Viaduct piers were formed on a grouted rock armour weir, with stones intermittently discharged along this weir to maintain its profile. The immediate cause of the collapse of Pier 4 was as a result of the undermining of the weir that surrounds and supports Pier 4 through the action of scouring. This was as a result of a combination of factors: An inspection carried out on the Malahide Viaduct three days before the accident did not identify the scouring defects visible at the time; A scour inspection undertaken in 2006 did not identify the Malahide Viaduct as a high-risk structure to the effects of scouring; Iarnród Éireanns likely failure to take any action after an independent inspection carried out on the Malahide Viaduct in 1997 identified that scouring had started at the base of Pier 4 and that the rock armour weir was “too light for the job”; The historic maintenance regime for the discharge of stones along the Malahide Viaduct appears to have ceased in 1996, resulting in the deterioration of the weir which was protecting the structure against scouring. The above factors were necessary for the accident to happen. Contributory to the accident happening were the following factors: Iarnród Éireann had not developed a flood/scour management plan at the time of the accident, despite the IRMS Implementation Review (2001) and the AD Little Review (2006) recommending that this plan be developed. Contributory to Iarnród Éireann not developing this flood/scour management plan was the fact that the Railway Safety Commission closed this recommendation in 2008; Engineers were not appropriately trained for inspection duties, in that the inspections training course they completed was an abridged version of the intended format, and there no formal mentoring programme, for Engineers on completion of this course; RAIU iv Investigation Report 2010 – R004 Rev 2 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 There was a shortfall in Iarnród Éireann‟s suite of structural inspection standards in that a standard which provided guidance for inspectors in carrying out inspections was not formalised; There existed an unrealistic requirement for patrol gangers to carry out annual checks for scour, as they do not have access under the structure and in addition, they did not have the required specialist training/ skills to identify defects caused by scouring; A formal programme for Special Inspections for structures vulnerable to scour was not adopted, as per Iarnród Éireanns‟s Structural Inspections Standard, I-STR-6510, at the time of the accident. Underlying factors to the accident were: There was a loss of corporate memory when former Iarnród Éireann staff left the Division, which resulted in valuable information in the relation to the historic scouring and maintenance not being available to the staff in place at the time of the accident; There was a dearth of information in relation to the Malahide Viaduct due to Iarnród Éireanns failure to properly introduce their information asset management system; Iarnród Éireanns inadequate resourcing of Engineers for structural inspections to be carried out at the Malahide Viaduct; Iarnród Éireanns failure to meet all the requirements of their Structural Inspections Standard, I-STR-6510, in that: o Visual inspections were not carried out for all visible elements of structures; o Bridge Inspection Cards, for recording findings of inspections, were not completed to standard or approved by the relevant personnel; o A formal programme for systematic visual inspections of all elements of a structure, including hidden or submerged elements, despite an independent review recommending that Iarnród Éireann implement this programme in 2006. Immediately after the accident, Iarnród Éireann carried out inspections on over a hundred viaducts on the network. Iarnród Éireann have now reinstating the Malahide Viaduct, ensuring that the overall structure has been significantly strengthened, that the weir profile has been restored and improved. Iarnród Éireann are currently reviewing all the Civil Engineering technical standards in order to improve the content, readability and practicable implementation of these standards. Improved control mechanisms are being introduced to ensure compliance with these standards. A competency management system is also being implemented to ensure the appropriate training is received by Engineers. RAIU v Investigation Report 2010 – R004 Rev 2 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 In relation to tracking recommendations made by independent organisation, the Railway Safety Commission has formalised their system for closing recommendations, and is now, in conjunction with Iarnród Éireann developing an action plan to close all outstanding recommendations. As a result of the findings of this RAIU investigation, the RAIU have made fifteen safety recommendations. Thirteen safety recommendations have been made to Iarnród Éireann, one safety recommendation has been made to the Railway Safety Commission, and one joint recommendation has been made to Iarnród Éireann and the Railway Safety Commission. Recommendation 1 Iarnród Éireann should put appropriate interface processes in place to ensure that when designated track patrolling staff (who report to two or more divisional areas) are absent from their patrolling duties, that appropriate relief track patrolling staff are assigned to perform these patrolling duties. Recommendation 2 Iarnród Éireann should amend the Track Patrolling Standard, I-PWY-1307, to remove the requirement for track patrollers to carry out annual checks for scour. Recommendation 3 Iarnród Éireann should formalise their „Civil Engineering and Earthworks Structures: Guidance Notes on Inspections Standard‟, I-STR-6515, which should include guidance for inspectors on conducting inspections and identifying structural defects. On formalising this document Iarnród Éireann should re- issue, in the appropriate format, to all relevant personnel. Recommendation 4 Iarnród Éireann should introduce a verification process to ensure that all requirements of their Structural Inspections Standard, I-STR-6510, are carried out in full. Recommendation 5 Iarnród Éireann should ensure that a system is put in place for effective implementation of existing standards and to manage the timely introduction of new and revised standards. Recommendation 6 Iarnród Éireann should ensure that a programme of structural inspections is started immediately in accordance with their Standard for Structural Inspection, I-STR-6510, and ensure that adequate resources are available to undertake these inspections. RAIU vi Investigation Report 2010 – R004 Rev 2 Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009 Recommendation 7 Iarnród Éireann should carry out inspections for all bridges subject to the passage of water for their vulnerability to scour, and where possible identify the bridge